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WELL DESTRUCTION PERMIT SCANNED �� 1 <br /> 09 /fes/1 Z/� PUBLIC WATER SYSTEM[]Yes ❑Nn <br /> SAN JOAQUIN COUNTSENVIRONMENTAL HEALTH DEPARTMENT 304 E WEBLst AVE 3.1, <br /> 3`1,F[fLOORR-S'J�"q�CFJJ�TO' A 95202- (209)468-3420 <br /> NON-REFUNDARLf PER •s CALL(209 953-7697 FOR INSPECTIONS "I_�r,+,�}x1��S 1 �1E, R NOM DATE 1titilllE) <br /> J08 ADDRE MWW <br /> CITYPLIP I N <br /> OWNER <br /> (° U PPHOL-46NE <br /> �J /y <br /> OWNER AD SS .��'L CITVISTATFJZH` IU (A► m <br /> CUNTRACTO C.// PHONE <br /> CONTRACTOR AUURESS CITYISTATE/ZIP I~ Z <br /> + <br /> 457 WELL DRILL.INC, LICENSE NUMBER EXPIRATION UATF. 3 <br /> PERFORATION CONTRACTOR PHONE <br /> I PERFORATION CONTRACTOR ADDRESS CITY/STATE/ZIP <br /> ❑ C-57 Well Drilling License Number '-Expiration Date <br /> ❑ Bureau of Alcohol,Tobacco and Firearms-Users of High Explosives License Number Expiration Date' <br /> ❑ CHP Hazardous Material Transportation for Explosives License`Dumber -._ Expiration Date +` <br /> r ❑ San Joaquin County Sheriff-Coroner Explosives Application and Permit License Number Expiration Date <br /> I ❑- California Occupational Safety Health-Blaster License Number Expiration Date <br /> REASON FOR DFSTRUCTION ❑ Dry ❑ Replacement Well ❑ Caved In ❑ Pit Well ❑ Inactivev <br /> ❑ Test Hale r fv <br /> I Detected!Suspected Well Water Contaminant(&): <br /> Adjacent property with contamination (Address): <br /> Known Soil)Water contaminants at adjacent property: <br /> EXISTING WELL CONSTRCCTION DETAILS❑ Open Bonom Gravel Pack 13Uncased 11Other <br /> Well Log copy attached El Yes ;�T No Grout Seal ❑ No .❑ Yes ft below ground surface(bgs) Hole Diameter inches <br /> Well Conductor Casing ❑ Yes }YN. Depth of Conductor Casing ft bgs Diameter of Conductor Casino inches- <br /> Well Casing Diameler _ inches Tow Depth f//jIJJAJW ft Depth to Water-_ _ ft Depth of Casing ft bgs , <br /> DESTRUCTION SPECIFICA' jJ <br /> Sealing Material from ,tl bgs to!:70,-11 bgs Filler Material -::oat— frons to /&V ft bgs <br /> Well easing to be perforated by one of the following methods from R bgs to _fl bgs <br /> ❑ Mills Knife Numberofcuts every ft and/or <br /> ❑ Explosives ❑ Detonating cord: ❑ with projectiles every tt 11 without projectile I <br /> ❑ Detonating cord and boosters: El with projectiles,very-11. ❑ withoutprojecdle <br /> O Other <br /> Sealing+ aterial ❑ Neat Cement(941b hag/5-6 hat water) Sand Cement W rack mu/7 ga water ❑ Bentonite Pellets <br /> lidKentoolte(20% lid ❑ Manufacturer Spec%solids % Name ny ecs on Fite ❑ Specs Submitted <br /> Placement Method �prped ❑ Free Fall ❑ Other <br /> Seal Completion: B/Com Ic c with Mushroom Ca � - <br /> p p p l bgs ❑ Complete to Existing Surface Pad <br /> I HEREBY CERTIFY THAT 1 HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH S. ' <br /> JOAQUIN COUNTY ORDINANCES,STATE LAWS,AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE. I; <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT 1 AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> ' t , <br /> MIN4 UR D ANCE NOTICE REQUIRED FO NSPECTIONS <br /> CONTRACTORS SIGNATURE: f TIT& DA'L'E: � <br /> SOV- <br /> f I FT <br /> DEPARTMENT —ONLY ^} �� <br /> Application Accepted By `- Date 2 C'J... 'r_ Arca <br /> Destruction Inspection By f. Date_ 7�,.�r-�/�/J�,�j Employee ID# <br /> COMMENTS If <br /> J t" <br /> PE SC Received .hec Amount D to Permit/ Invoice# WellID4 <br /> Codes Info v as Remitted Service Request# <br /> / ..`� o2lD OLU3z <br /> E11043-02-00% <br /> N7,04 Well Dneun,on Pcrma Addendum 4404 kA—X-04 <br />